BACKGROUND: The aim of conservative
surgery for treatment of breast cancer is obtaining satisfactory aesthetic
results. Segment-based surgery, which must be followed by radiotherapy (RT), is
considered the treatment of choice for most breast cancer patients. Single-dose
intraoperative radiation in the tumor bed (IORT) is a promising radiation technique
that is more rapid than conventional RT and less exhausting for the patient.
The aim of this study was to evaluate the final aesthetic results of patients
who had undergone conservative surgery and treatment for early-stage breast
cancer consisting of primary closure of the operative wound and use of adjuvant
radiotherapy, either conventional RT or IORT, and assess the impact of several
variables on the results.METHODS: Primary closure of
the operative wound after conservative breast cancer treatment was performed in
66 patients. The patients were evaluated and photographed and their data
collected from medical records.RESULTS: Some degree of
asymmetry was observed in 40.4% of patients. The surgically treated breast
frequently appeared more aesthetically pleasing than the healthy breast,
especially in patients with large breasts (P = 0.052), in whom resection of the
upper quadrants improved the degree of ptosis and thus improved the appearance
of the treated breast (P = 0.002 and
P= 0.001, respectively). Use of periareolar incision (P = 0.008) was found to
be a predictor of good aesthetic results while the comorbidity of diabetes
mellitus and the use of chemotherapy were found to be predictors of poor
results (P = 0.046 and P = 0.073, respectively). CONCLUSIONS: Some degree of asymmetry often results in patients for whom remodeling of
mammary tissue is not possible. The factors of use of periareolar incision,
large breast volume, and tumor location in one of the upper quadrants are
predictors of a good aesthetic outcome, while use of chemotherapy, diabetes
mellitus, and tumor location in the lower quadrants are negative predictors.
Use of IORT yields aesthetic outcomes comparable to those of conventional RT in
terms of extent of scarring.

Keywords: Breast neoplasms. Radiotherapy. Plastic surgery/methods.

INTRODUCTION

Breast cancer is the second most common type of
cancer in the world. Apart from non-melanoma skin cancer, it is the most
common cancer in women, being responsible for approximately 22% of all cancer
cases newly diagnosed every year in women. Breast cancer is second most common
cause of death by cancer in women, preceded only by lung cancer1,2,
with a worldwide survival rate after 5 years of 61%1. In
2011, it had been estimated that 230,480 women and 2,140 men would be diagnosed
with invasive breast cancer in the United States and that 39,970 (39,520 female
and 450 male) deaths would be attributable to this diagnosis2. In
Brazil, 49,240 new cases had been expected in 2010, indicating a breast cancer
incidence of 49 cases per 100,000 individuals. In the Southeast region, the
incidence is even higher, estimated at 65 per 1000,000 inhabitants. In 2010, it
was estimated that 11,860 (11,735 female and 125 male)1 deaths would
be attributable to breast cancer.

Risk factors for breast cancer in women are
closely associated with reproductive factors, including early menarche, use of
oral contraceptives, use of hormone replacement the­rapy (HRT), nulliparity,
first pregnancy after age 30, and late menopause. As such, it is associated
with the urbanization of society, and thus women of high socioeconomic status
are particularly at risk1. Although breast cancer is relatively rare
before 35 years of age, its incidence increases rapidly and progressively
thereafter. According to the World Health Organization (WHO), the cancer
population-based cancer registries of several continents1 indicated
a 10-fold increase in incidence rate, adjusted by age, in the 1960s and 1970s.
In developed countries, incidence rates for breast cancer started to decline in
2000 and have been generally stable since 2003. At the same, death rates have
been consistently decreasing since 1990, primarily due to early detection, improved
treatment, and, most recently, decrease in incidence2. In Brazil,
cancer mortality rates remain high, most likely due to diagnosis at advanced
stages1.

Although the prognosis remains less favorable
in Brazil and other developing countries, it is important to recognize that in
the past several decades have seen enormous advances in multidisciplinary
breast cancer treatment throughout the world. Several factors have contributed
to ensuring the pro­vision of less aggressive but increasingly effective and
safe forms of detection and treatment that value quality of life and have
favorable aesthetic results. These include early diagnosis,
determination of stage through axillary sentinel lymph node (LS) biopsy,
radiotherapy (RT), chemotherapy therapy (CT), hormone therapy (HT), and
conservative sur­gical breast remodeling3.

For over 80 years,
radical surgical treatment of breast cancer had been the universally accepted
surgical approach. Veronesi et al.'s4-6 research provided for
significant advances in surgical treatment by showing that in selected cases
(gene­rally, cases at initial stages), conservative surgical
treat­ment led to outcomes similar to those obtained with radical
surgery concerning locoregional relapse and global sur­vival7,8.
With this finding, conservative breast surgery has become increasingly common
over the past 30 years, being accepted world­wide as the treatment of choice in
up to 80% of primary breast cancer cases8. The advantages of using
conservative surgical te­chniques are reduction in breast deformity by
preservation of the majority of the mammary parenchyma, reduction in morbidity,
reduction of surgical impact on breast functioning, and improved aesthetics,
all of which improve the psychosocial aspects associated with tumor
resectioning3,4,7,8.

Although most patients initially expressed
satisfaction with the possibility of maintaining their breast after tumor
resection, it has become clear that expectations have been increasing, with
many patients now believing that conservative surgery should result in
healthy-looking, symmetrical breasts without residual deformity. However, these
results are not always obtained in practice, with the aesthetic results being
considered unacceptable in up to 30% of the cases8. Con­sidering
that an acceptable aesthetic result is the major aim of conservative surgery
when compared to mastectomy9, conservative surgery generally does
not fulfill expectations. It particularly fails to do so when resected mammary
tissue is repaired by simply pulling together the margins of the
sur­gical area, a technique that may lead to difficulty with
repairing sequels and to aesthetic deformities consequent to deficiency of
skin, subcutaneous cellular, and gland tissue; loss of projection; and
retraction and distortion of the breast and papillary-areolar complex (CAP).
These defects may be worsened by external postoperative RT, which must be performed almost daily for 4 to 6 weeks
following surgery7-11. Besides increasing risk of local
complications due to the pre­sence
of an operative wound, RT also poses the risk of vascular
changes, intense fibrosis, aesthetic dissatisfaction, and physical and
psychological discomfort12-17.

Veronesi et al.12 found that over
the course of breast can­cer treatment, the majority of cases of relapse
occurred in regions adjoining the site of previous segment resectioning, and
only a minority in other mammary quadrants. This finding suggests that in cases
of conservative breast surgery, partial mammary irradiation yields results
comparable to those of external total irradiation and provides several
benefits, including a briefer treatment period, lower costs, fewer side
effects, and possibly better aesthetic results. Among the several types of
partial breast radiation aiming at minimizing total treatment time while
maintaining historical levels of local relapse, single-dose intraoperative
radiation in the tumor bed (IORT) with electrons has been found to be
particularly promising, with phase I and II studies confirming its safety
and effectiveness15-20. In Brazil, a few centers already use this
new and promising radiation technique.

Changes in the traditional conceptual approach
to breast cancer treatment, which is based on the use of invasive
oncological procedures, requires an adaptation to the repara­tion concept10.
Immediate corrections are now popular because they yield
favorable aesthetic and psychosocial re­sults without significantly interfering
with the diagnosis or increase risk of relapse. Depending on the residual
volume of the contralateral breast, patient preference, local tissue
conditions, and often (erroneously) on the patient healthcare plan, the margins
of the surgical area may be simply pulled and stitched together or the
remaining mammary tissue may be remodeled. In general, the breast remodeling
techniques performed to recover lost volume by inserting an implant or
performing more elaborate techniques using myocutaneous grafts are mostly based
on mammoplasty and mastopexy, with the goal of symmetrization of the
contralateral side. Being considered efficient, these techniques are widely
used and increasingly referred to as forms of "oncoplastic surgery"21,22.

Considering that the efficacy and healing
potential of cu­rrent cancer treatments are already established, it is now
important to evaluate the different aesthetic results that they yield. Dong so
will assist surgeons in selecting among the different breast restructuring and
RT approaches to use with their patients. In the many studies23-25 that have attempted to identify the predictors of good aesthetic results, the
most commonly evaluated factors have been scar visibility and appearance,
patient age, body mass index (BMI), tumor localization and size compared
to breast size, and use of adjuvant therapies such as RT and CT8,23-26.
However, the most widely used evaluation methods are invariably
subjective, leading to results of questionable re­liability
and, therefore, doubts regarding the extent to which these factors truly affect
cosmetic results24,27. Numerous studies have addressed the topic of
early-stage breast cancer treatment3-8,11-14,21,28, but
few have evaluated aesthetic outcomes9,10,22-27,29-43 and even fewer
the impact of IORT on outcomes15-20. To fill this research gap, this
study evaluated the impact of several variables on the final treatment and
aesthetic outcomes of patients with early-stage breast cancer treated with
conservative surgery for tumor resection and primary wound closure followed by
adjuvant RT, either conventional RT or IORT.

METHODS

This study
prospectively evaluated the progression of 66 breast cancer patients with
invasive ductal carcinoma defined as early stage, i.e., a cancer stage earlier
than T2N1M0, treated using a conservative surgical approach that aimed at
primary closure of the surgical margins either with or without ma­mmary
prosthesis and no remodeling of the mammary tissue. All surgeries were
performed bet­ween May 2008 and January 2011, and the postoperative follow-up
period ranged from 6 to 20 months. All patients signed an informed consent form
after verbally agreeing to participate in the study.
The project was submitted to the Ethics and
Research Committee of the A. C. Camargo Hospital and approved on October
14, 2008 under number 1122/08. Figure 1 shows the most common breast cancer
treatments currently provided, with the patients eligible for this study
highlighted in blue.

 Surgery for tumor resection:
Sectorectomy, tumorectomy, quadrantectomy,
or lumpectomy, also referred to as segment-­based surgery;

 Associated therapy: Either
conventional RT or IORT;

 Breast restructuring: Primary
closure of the operative wound by the pulling together of all anatomical planes
or immediately reconstruction with silicone gel-filled breast implants without
repair or aesthetic surgery of the contralateral breast.

Exclusion Criteria

The following were the exclusion criteria for
this study:

 Sex: Male.

 Previous history of any of the
following:

- RT in the breast or thorax for any
reason;- Collagen disease;- Psychiatric illness or any other
condition that might prevent study compliance.

 Type and stage of tumor disease

- Positive margins upon
anatomopathological evaluation;- Type of tumor other than invasive
adenocarcinoma;- Any tumor lesion in stage III or
IV;- Stage II with diameter 3 cm or
larger;- Presence of 3 or more positive lymph
nodes;- Positive lymph nodes other than
axillary nodes;- Multicentric carcinoma in more than
1 quadrant or carcinomas that are separated
by 4 cm or more;- Previous history of breast cancer
in the same breast.

 Associate
therapy: Any mastectomy technique, whether simple or skin- sparing
mastectomy; a modification of the Patey, Madden, and Auchincloss ra­dical
mastectomy; or any other form of radical mastectomy.

 Breast restructuring:

- Reconstruction that occurred
relatively late;- Remodeling after tumor removal;- Reconstruction with a pedunculated
or free myo­cutaneous flap;- Use of expanders before silicone
implant.

In the
postoperative period, patients were re-evaluated and photographed from the
front while resting and while elevating the upper limbs, as well
as from the left and right oblique positions and from the left and right sides.
A close-up photograph of the scar was also taken (Figure 2). Data
regarding patient physical and clinical variables, including breast characteristics,
co-morbidities, use of adjuvant therapies, quadrant treated, and type of
incision, were collected by re­trospective review of medical records. Degree of
breast ptosis was determined using the Regnault classification with some modification
according to the following scheme (Figure 3):

 Score
0 or no ptosis: Absence of submammary grooves;

 Score 1 or slight ptosis (partial
ptosis or pseudoptosis in the original classification): Presence of
sub­mammary groove below the areola;

 Score 2 or moderate ptosis (degree
I in the original classification): Presence of submammary groove with areola
within it;

 Score 3 or pronounced ptosis
(degrees II and III in the original classification): Presence of submammary
groove above the areola.

Evaluation of aesthetic results was performed
using the Moro and Ciambellotti27 classification according to the
following scheme (Figure 4):

 Satisfactory:
Presence of CAP asymmetry, more than 1/3 loss of mammary volume, or mammary
retraction;

 Poor: Presence of 2 or more of the
factors described above.

Extent of scarring, changes in shape and
position, dynamic and static retraction, and shape and coloration of the CAP
were evaluated. The evaluation concluded with an as­ses­sment of the
approximate volume of the healthy breast and determina­tion of whether the
healthy or treated breast had a more pleasing ap­pearance, disregarding the
appearance of the scar and considering only volume changes, shape, and CAP
position, conducted by 3 plastic surgeons. The factors evaluated were
classified into the following categories in accordance with the literature9,24.

Exploratory analysis of the data was conducted
and associations between the variables were verified using the exact Fisher
test at a 95% (P < 0.05) confidence level and XLSTAT software.

RESULTS

Surgical
Treatment

Among the 66 patients identified as having
undergone primary closure of the operative wound after conservative treatment
of breast cancer, all were found to have also undergone RT. Regarding the type
of RT, 19 patients had undergone IORT at a total dose of 21 Gy while 47 had
undergone conventional RT at a total dose of 55 Gy, with the most widely
used approach of the latter being 25 sessions at a dose of 180cGy of the entire
targeted breast and 5 reinforcement sessions at a dose of 200 cGy in the tumor
bed.

Patient-Dependent
Factors

The mean age of the patients was 55.9 years and
ranged from 33 to 82 years.

Regarding
race/ethnicity, 56 identified as white, 4 as Asian, 4
as biracial, and 2 as black.

Regarding weight
classification according to BMI, 1 patient was underweight (BMI
<18.4), 29 patients were normal (BMI < 24), 21 were overweight, and 15
were obese. Regarding comorbidities, 26 patients were hypertensive, 9 had DM, 4
were smokers, and 11 were ex-smokers. The relationship between extent of
scarring and comorbidities is shown in Figure 5.

Tumor-Dependent Factors

Regarding tumor localization, the tumor was
located in the upper lateral quadrant (QSL) in 22 patients, the upper
qua­drant (UQS) in 10, the intersection of the lateral quadrants (UQL) in 9,
the medial upper quadrant (QSM) in 8, the medial lower quadrant (QIM) in 5, the
central quadrant (QC) in 4, the intersection of the lower quadrants (UQI) in 4,
the lower lateral quadrant (QIL) in 3, and the intersection of the medial quadrants
(UQM) in 1.

Treatment-Dependent
Factors

Regarding type of incision used in tumor
resectioning, 30 patients had undergone arched incision; 16 periareolar
incision; 14 radial incision; 6 lower vertical incision, either in the groove
or in the "T" (Figure 6). The relationship between extent of scarring and type
of incision or procedure is shown in Figure 7.

The relationship between extent of scarring and
type of RT is shown in Figure 8.

Among all 66 patients, only 7 had undergone
implantation of mammary implants to compensate for significant volume deficit,
and only 31 had required and consequently undergone adjuvant CT. In contrast,
62 patients had required HT, such as tamoxifen, arimidex, or imatinib therapy.

Evaluation

Regarding scar quality, the extent of scarring
was con­sidered subtle and almost absent in 21 patients, slight in 26,
moderate in 10, and pronounced in 9. Regarding change in CAP position,
no change was observed in 18 patients; slight change in 40, of which the change
was positive in 32, negative in 5, and neither positive nor negative in 3;
moderate and positive change in 4; and not possible to eva­luate in 4 because
the areola had been resected together with the tumor. Regarding categorization
using the Moro and Ciambellotti classification27, the result was
considered excellent for 18 patients, satisfactory for 22, and poor for 26.
Breast volume was estimated at less than 200
cc in 6 patients, 200 to 400 cc in 12, 400 to 600 cc in 33, and greater
than 600 cc in 15. The relationship between the extent of scarring and
estimated volume of the breast is shown in Figure 9.

Regarding the degree of mammary ptosis, none
was observed in 4 patients, mild ptosis in 10, moderate ptosis in 28,
and pronounced ptosis in 24. Regarding aesthetic quality, the surgically
treated breast and the untreated breast were considered equally aesthetically
pleasing in 7 patients, the untreated breast more aesthetically pleasing in 26,
and the treated breast more aesthetically pleasing in 33. Regarding changes in
shape, none was observed in 24 patients, minor changes in 27, moderate changes
in 12, and pronounced changes in 3, with all changes considered an indication
of worsening shape. Regarding extent of static retraction, none was observed in
36 patients, slight retraction in 24, moderate in 5, and pronounced in 1.
Regarding extent of dynamic retraction upon lifting the upper limbs, none was
observed in 30 patients, slight retraction in 17, moderate in 14, and
pronounced in 5 (Figure 10).

DISCUSSION

Many studies have evaluated the aesthetic
results of conservative breast surgery and identified the factors that
might influence them. Regarding patient-dependent factors, being relatively
thin, young, and light complexioned is associated with favorable aesthetic
results. Regarding treat­ment-­dependent factors, resectioning of a large
quantity of tissue and use of CT have been associated with unfavorable
aesthetic results9,24. In their evaluation, some studies have
assumed the existence of a direct relationship between scar visibility and
extent of change in body image, and many have confirmed the existence of a
relationship between scar visibility and aesthetic appearance24,25.
As the results of these studies indicate that the extent of surgical scarring
influences final aesthetic appearance, this study evaluated several factors
that might directly impact the extent of scarring. Of the patient-dependent
variables that were evaluated, which included age, BMI, race/ethnicity, breast
volume, and comorbidities, only the comorbidity of DM was found to be
significantly associated with moderate or pronounced scarring (P = 0.046). Of
the tumor-dependent variables examined, no correlation was found between
tumor location and extent of scarring, but a significant
cor­relation was found between tumor location and extent of
postoperative mammary retraction (P = 0.007). Of the treatment-dependent
variables examined, a significant relationship was found between the type
of incision and extent of scarring (P = 0.008). Among those patients with only
subtle, almost absent scarring, a significant percentage had undergone
periareolar incision; among those with slight scarring, a significant percentage
had undergone arched in­cision; and among those with moderate or
pronounced scarring, a significant percentage had undergone radial incision.
These results indicate that periareolar incision yields the best aesthetic
outcome and radial incision the worst. Among the treatment-dependent variables
examined, use of CT was found to yield worse aesthetic outcomes than use of HT
at a statistical level (P = 0.073) that almost reached significance (P = 0.05).

As RT is a
fundamental component of conservative treatment
of breast cancer, many studies have evaluated its effects on aesthetic
outcomes12,28. While these studies all iden­tified
conventional RT as an isolated factor associated with unfavorable aesthetic
outcomes, particularly when performed preoperatively26,28, the
current study was the first to examine whether IORT is associated with specific
aesthetic outcomes. Comparison of the 71.2% of patients who had undergone
conventional RT with the 8.8% who had undergone IORT indicated no significant
differences in the extent of scarring in these 2 groups. This finding indicates
that administration of a single dose of 21 Gy of radiation, per IORT, and
administration of 30 sessions of a total dose of 55 Gy of radiation, per conventional
RT, affects the extent of scarring to the same extent. Regarding patient
morphology, Clough et al.26 suggested a relationship between
unfavorable cos­metic results and the existence of very little residual breast
volume, and Taylor et al.9, among many other authors, found that
cosmetic results decrease in proportion to resected mammary volume. As breast
volume is a subjective measure, the initial estimations made by the observing
doctors in this study were confirmed by other clinicians, and the estimated
breast volume values subsequently evaluated to determine whether they
corresponded with the extent of breast ptosis, a more objective measure. A
significant relationship was found between the extent of ptosis and breast
volume (P < 0.001), indicating that ptosis should be measured in future
evaluations as a means of increasing the reliability of the results.

The results of the analysis of the relationship
between estimated preoperative breast volume and identification of the more
aesthetically pleasing breast almost reached a level of significance (P =
0.052). Specifically, neither breast was considered more aesthetically pleasing
when mammary volume was estimated at < 200 cc (i.e., small breasts), while
the untreated breast was considered more aesthetically pleasing when mammary volume was estimated at 200 to
400 cc (a volume considered aesthetically ideal), likely because the
volume became inadequate with surgery. In contrast, the treated breast was
considered more aesthetically pleasing when
mammary volume exceeded 400 cc, most likely be­cause upon
removal of breast tissue (together with the tumor mass, independently of the
resected volume), the breast had a more aesthetically adequate volume, and was
therefore considered more aesthetically pleasing when compared to the oversized
contralateral breast (Figure 11).

Curiously, no significant relationship was
found between the use of mammary implants and identification of the more
aesthetically pleasing breast, likely because the implant was used only to
replace volume that had been resected, as the parameter for choice of implant
is the weight of the removed surgical piece. While implantation improves
symmetry, it does not necessarily improve overall aesthetic appearance. While
several local flaps can be placed in the empty space left after removal of the
tumor, it is often impossible to replace lost breast volume and give proper
shape to the breast. Therefore, in many cases mammary remodeling should be
provided when performing contralateral reducing mammoplasty as part of breast
cancer treatment, as it is known that performing both surgical techniques at
the moment of treatment may positively influence outcomes. Unfortunately, not
all patients have access to these procedures10.

Examination of the relationship between
aesthetic out­co­mes and several factors, including tumor-dependent
fac­tors, such as tumor site; patient-dependent variables, such as BMI and
age; and treatment-dependent factors, such as type of RT and extent of shape
change and of postoperative static or dynamic retraction, indicated that
outcomes were significantly associated with only the extent of postoperative
static and dynamic retraction (P = 0.012 and P = 0.026, respectively). While
approximately 80% of patients with tumors in the upper quadrants had
experienced change in CAP position, most patients with tumors in the lower
quadrant did not, indicating a significant association between change in CAP
position and quadrant (P = 0.002).

Classification of postoperative ptosis was most
accura­te in patients who had experienced an increase in the extent of
ptosis. The classification was confirmed in the signi­ficant association found
between change in CAP position and identification of the more aesthetically
pleasing breast (P = 0.001), as 90% of patients showed an improvement in the
position of the CAP; this can be easily explained by the fact that the CAP
ascended as a result of resection of tis­sue above it.

In accordance with the literature10 regarding the importance of the correlation between extent of ptosis and
out­comes, patients with pronounced ptosis (>3 cm of the sub­mammary
groove) were found to be more satisfied with the outcome after the repairing
procedure had been performed compared to those with less pronounced ptosis
(<1 cm). This finding indicates that when surgery is performed in the upper
quadrants (particularly the QSM), resection of the tissue along the line
between the sternal furcula and the areola will automatically elevate and
better position the CAP in a manner similar to the "point A of Pitanguy," the
highest point used in marking in reducing mammoplasties, equivalent to the
ideal position of the CAP29. It is also clear, even if not
significant, that performing surgery in the lower quadrant is very likely to
have a negative impact on breast shape.

The study results suggest that when the tumor
is locali­zed in the lower quadrants (QIL, QIM, or UQI) and if the breast
is not remodeled, as in the cases described in this study, the CAP will remain
at the same height and the breast will partially lose shape, giving the
impression that is a worsening of ptosis, i.e., a relative ptosis, since there
was no change in the height of the CAP but only in the volume of the lower pole
that caused the CAP to be in a position near the caudal limit of the breast.
Clough et al.8 agree that patients with tumors in the lower
quadrants are the primary, although not only, candidates for surgery
accompanied by mammary remodeling instead of only primary closure of the
surgical field.

All the results suggest that in the absence of
retraction, mammary volume will decrease when the tumor is resected in a
larger-than-ideal breast, elevating the CAP position in a manner associated
with improvement of ptosis, thus making the treated breast more aesthetically
pleasing compared to the healthy contralateral breast in a significant number
of cases. This suggestion alone constitutes a reasonable indication for
performing contralateral mammoplasty. Although the li­terature states that it
is not uncommon for the surgically treated breast to be more aesthetically
pleasing than the healthy breast, few studies describe the need to operate on
the contralateral breast as part of breast cancer treatment30. Ideally,
conservative breast surgery should not result in asymmetry or residual
deformity, a fact not mentioned in most studies7,10,31. The unfavorable
unaesthetic results of conservative breast surgery are invariably related to
differences in the shape and volume of the breasts. According to Bajaj et al.30,
the percentage of asymmetry resulting from segment-­based surgery and primary
closure of the surgical margins may reach 35%, making it an important negative
factor in the aesthetic evaluation of the results. However, even a high degree
of asymmetry may not be perceived during the in­traoperative period, only
becoming noticeable with time, particularly during healing or after RT32.

According to the
Moro and Ciambellotti classification27, only 18 patients obtained excellent outcomes,
meaning that 48 had
experienced at least one negative result, whether change in CAP position,
volume change, or ob­vious retraction. It is important to note that the
surgically treated breast was considered more aesthetically pleasing than the
healthy breast in 40% of the patients who had obtained satisfactory
outcomes and, surprisingly, 70% who had obtai­ned poor outcomes. These
results suggest that when using the Moro and
Ciambellotti classification27, a poor
outcome indicates that surgery
resulted in asymmetry, lack of volume, and/or inadequate CAP position, and does
not mean that the surgery itself was inadequateon the contrary, as the
surgically treated breast was considered more aesthetically pleasing. These
results thus lead to the conclusion that in a great number of cases, the
quality of the surgery was good despite the resulting asymmetry, which could
have been improved if the contralateral breast had been made more symmetrical.

The importance of
performing mammary remodeling at the time of tumor resectioning was reinforced
by Clough et al.'s26 study of aesthetic sequelae after conservative
surgery in 3 groups of patients. One group was composed of patients who had
undergone adequate breast surgery and required only symmetrization to improve
aesthetics. At the other extreme, one group was composed of patients with clear
breast deformities, including retractions and significant volume and shape
deficits. Treating this group required total resectioning of the remaining
mammary tissuemastectomyfollowed by total breast reconstruction using more
complex techniques, such as distant flap manipulation. Although the need for a
surgical approach was evident in this group, the patients were reluctant to
undergo surgery because mastectomy had not been initially indicated as part of
their breast cancer treatment. In such groups, it is important to alert
patients to the possibility of poor outcomes and obtain their permission to
perform mastectomy because performing mastectomy, including skin-sparing
mastectomy, with immediate reconstruction ultimately leads to better outcomes
and, most likely, fewer complications. The last group posed the most
significant treatment challenge, being composed of patients who had obtained
inadequate surgical outcomes. The primary challenge was that the conservatively
treated breast had invariably been subjected to RT, scarring the tissue and
making it fibrous, and thus unpredictable in terms of its reaction to future
surgical manipulation. In this group, the results were not encouraging, as
indicated by a high complication index in most cases.

Several studies
have indicated that patients with predominantly fatty breasts may experience
late complications, such as steatonecrosis and loss of breast volume, that
result in asymmetrical reconstruction. In these patients, the defect
resulting from oncological surgery should be cor­rected in manner that
leaves the treated breast larger than the contralateral breast to make it
possible to reduce the differences in the future. An outcome considered very
good in the immediate postoperative period may, after RT, become compromised
due to fibrosis and retraction over the remaining breast tissue7.

Although IORT was
found to yield aesthetic results re­garding scarring comparable to those of conventional RT in this study, the manner in which the
irradiated breast tissue will react to future surgical manipulation is unknown,
as the patients were not followed up by our institute. Concerning the
psychological aspects of patients, Homberg et al.33 identified
excessive aesthetic concerns prior to surgery and/or excessive valorization of
the breasts as an aspect of body image as predictors of poor aesthetic
prognosis. Ho­wever, such predictors must be identified with the utmost
caution.

Approaching cancer
using mammoplasty techniques may, besides improved aesthetic appearance, offer
as advantages technical facilitation of a broad surgical field and
better out­comes, including scarring to only the slight ex­tent that
occurs in plastic surgery and a resected piece larger than that when using
techniques aiming at simple primary closure of the surgical field. Despite
increasing surgical time, contralateral breast symmetrization provides
additional tissue for histopathological analysis and significantly improves
aesthetic results in the immediate postoperative period34. However,
popularization of the so-called oncoplastic technique is increasingly being
associated with oncological teams, leading it to lose popularity among plastic
surgeons and the emergence of conflicts of interests in selected cases when, by
resecting enough tissue to allow adequate oncological analysis, the breast
becomes deformed or too small. As postulated by Cardoso et al.24,
resectioning of large quantities of tissue may result in poorer aesthetic
outcomes. In these situations, a team composed of an oncological surgeon and an
associated plastic surgeon is in the best interest of the patient26.

Collaboration
between the mastologist and a plastic sur­geon may
also increase the therapeutic efficacy of the o­ve­rall treatment by
reducing costs through the provision of a single surgical procedure rather than
multiple procedures performed by different specialists. In the same manner,
col­laboration can decrease the psychic morbidity associated with
undergoing multiple surgical operations. These aspects have been widely
accepted by patients, many of whom have seen such collaboration as an
opportunity to correct and/or improve the appearance of their breasts20,34.
While emphasizing the advantages of collaboration in the surgical treatment of
breast cancer, this study, as has others, avoided using the term oncoplasty, as its use may suggest the participation of
professionals not qualified in plastic surgery, therefore compromising the
final results10.

CONCLUSION

In the
conservative treatment of breast cancer, remodeling of residual
mammary tissue and performance of contra­lateral mammoplasty immediately after
tumor removal is ideal. However, provision of treatment that pro­vides better
results is often not possible. In such cases, the operative wound is primarily
closed by simple closure of the surgi­cal margins, frequently leading to
asymmetry, a result that alone can yield unsatisfactory aesthetic results.
Nevertheless, in some cases, mainly in patients who have large breasts and/or
have undergone resectioning of the upper quadrants, factors that improve
ptosis and appearance, the surgically treated breast is more aesthetically
pleasing than the healthy breast despite the asymmetry. However, the converse
has also been observed, with patients who have undergone resectioning of the
lower quadrants often being left with a misshapen and aesthetically unpleasing
treated breast. Therefore, when the tumor is located in the upper quadrants,
contralateral mammoplasty for symmetrization, even if performed at a later
period, is ideal, whereas tissue remodeling, per­formed immediately in
anticipation of subsequent RT (and associated with contralateral mammoplasty,
if necessary), may be required when the tumor is located in the lower
quadrants. Regarding the factors that predict the best aesthetic results, the
use of periareolar incision was found to decrease the extent of scarring
whe­reas the presence of the comorbidity of DM and the use of CT were found
to increase it. The outcomes of IORT, a more rapid and less exhausting means of
RT compared to conventional RT, were shown to be comparable to those of
conventional RT regarding aesthetic appearance of the breast and extent of
scarring.

Study conducted at the
Tournieux Plastic Surgery Clinic,
São Paulo, SP, BrazilSubmitted to SGP (Sistema de Gestão de Publicações/Manager
Publications System) of RBCP (Revista Brasileira de Cirurgia Plástica/Brazilian
Journal of
Plastic Surgery).Study presented for promotion to a full member
of SBCP.Study awarded with the
Nemer Chidid Prize 2011.